Basic Interviewing

A Practical Guide for Counselors and Clinicians

Michel Hersen, Vincent B. Van Hasselt, Michel Hersen, Vincent B. Van Hasselt

• Publisher: Routledge
• Year: 2013
• eBook ISBN: 9781135885274
• Topic: Psychology
• Subtopic: Clinical Psychology
• Index: Psychology

This book offers clear and direct answers to the questions most frequently asked by students and trainees learning how to talk to clients and extract critical data from them. Its development reflects the old adage that "necessity is the mother of invention." For many years, the editors taught beginning level mental health clinicians. They found, however, no text to be satisfactory--including a number that they themselves were involved in producing. Some were too difficult; some were too simplistic; some were too doctrinaire; still others had missing elements.

Written in a reader-friendly "how-to" style, the chapters in Basic Interviewing are not weighed down by references. Rather, each contributor suggests readings for students and instructors who wish to pursue questions further.

After the initial overview chapter, there are 12 chapters addressing the nuts-and-bolts concerns of all clinicians that can be particularly vexing for neophytes. They cover a variety of issues from the most specific--like how to begin and end interviews--to the more general--like how to build rapport and identify targets for treatment. Throughout, rich clinical illustrations facilitate the pragmatic application of fundamental principles. Beginning graduate students in counseling and clinical psychology, social work, and other allied mental health fields, as well as psychiatric trainees, will find this text to be an indispensable companion.

1

General Issues

Jan Faust

Nova Southeastern University

The clinical interview is the foundation for all aspects of the practice of psychology. It is the primary mechanism by which psychological services are formulated and delivered. While most novice therapists believe the purpose of the clinical interview is exclusively for diagnosing, it is much more encompassing than mere classification of symptoms. The interview is the initial contact between therapist and client and sets the tone for many facets of therapist-client interaction. It is this early contact that will dictate the quality of the therapist-client relationship including the level of patient commitment to evaluation and treatment.

An effective interview is similar to a tightly choreographed dance in that the therapist must help set the tempo and tone of initial session(s) and guide the interviewee through a series of intricate steps. These steps weave together communication of empathy, validation, and understanding while simultaneously extricating information pertinent to the task at hand. The purpose of the latter, information gathering, is to develop a basic coherent conceptualization, a clinical frame of reference by which to understand the symptoms presented. In order to achieve the goals of the interview, practice is crucial for the novice therapist. The interview experience, first through role play and then through direct client contact, facilitates integration of information gathering skills with therapy relationship building skills. Ultimately such integration enhances assessment and treatment planning. In fact, the majority of surveyed graduate students endorsed critiqued role-playing as the most important didactic for honing their interviewing skills and improving their clinical performance.

It is evident then that the goal of the clinical interview is multifaceted including, but not limited to, the detective work in establishing the parameters of the presenting problem and problem conceptualization. Other goals include developing a working relationship with the patient and setting the foundation for therapy. This chapter identifies those factors and issues that are critical to the goals of the diagnostic interview. They include basic skills such as knowledge, therapist communication ability, and people/social skills, and more advanced skills which include integrating the specific parts of the clinical interview (e.g., mental status exam, medical interview, social history, etc.). Finally, critical issues which significantly impact the clinical interview are discussed. These include referral source, interview setting, confidentiality, client diversity, and issues specific to novices.

GETTING STARTED/THE BASICS

Knowledge

Requisite tools of the interviewer include a comprehensive foundation in psychopathology and diagnostic classification. Additionally, the interviewer should be knowledgeable about the impact life events and experiences have on people, in general, and specifically with respect to their psychopathology. Therapists need to consider the influence of culture and ethnicity on symptom manifestation and attitudes toward treatment. As society becomes a more diverse amalgamation of cultures, ethnic heritages, and subcultural blends, the complexity of symptoms increases. The role of client diversity in interviewing is covered in greater depth later in this chapter.

Empathy/People Skills

Finally “people skills” frequently are deemed to be the most important aspect of the interview and client contact. These behaviors are commonly referred to as non-specifics of therapy: appropriate social skills, ability to relate effectively and comfortably with people, and ability to empathize and convey such empathy through validation and understanding of others’ positions and plights. Empathy is derived from the Greek word empatheia which means passion. Passion, in this context, refers to the intensity of feeling one experiences in understanding another’s feelings and cognitions. In fact, a literal dictionary definition states, “Understanding so intimate that the feelings, thoughts, motives of one are readily comprehended by another” (American Heritage, 1983, p. 428). The therapist needs to understand the client to this depth and then be able to convey such understanding to that client. Hence, there is an experiential aspect to empathy such that, in our field, empathy is the ability to perceive and understand a person’s feelings “as if” the therapist were experiencing them and convey such experience to the client. The interviewer needs to listen to all client communications in order to understand the client. This includes not only words but body language, tone of voice, cadence of speech, and other non-verbal behaviors. Other non-specific behaviors such as timeliness to sessions and approach to the interviewer and staff are also important.

The interviewer’s ability to empathize with the client’s dilemma and associative experiences increases client trust. The client first experiences the therapist as an attentive listener and perceives the therapist as caring and concerned. Then the interviewee realizes that the therapist has the capacity to understand; hence, the interviewee is likely to perceive the therapist as competent and able to help. Finally, with the client’s realization that the therapist understands, he or she experiences hope for symptom/problem resolution. It is also probable that through the interviewer’s empathy and experiencing the problem “as if” he or she were in the client’s predicament, the therapist’s own comprehension of the problem increases.

The use of empathy and validation of the client’s emotional and other experiences is a critical tool. Once the client trusts the interviewer, the latter is often able to extract information that has never been disclosed previously. Such information may be embarrassing or frightening to the client. Interviewers need to cautiously approach such topics so as not to divulge, verbally or behaviorally, their own fear, shock, or embarrassment.

There are many ways to convey empathy which affords interviewers the opportunity to select a style that is comfortable for them. Some interviewers rely more heavily on paralinguistic validation, such as facial expressions and body gestures, than on verbalizations. Other interviewers are more comfortable with linguistics than non-verbal modes of communication. However, most clinicians utilize some combination of both. Other validation strategies include tone of voice, timing and rate of comments and questions, and area of questioning. Although these latter strategies appear to be trivial, they may be critical in the communication of empathy. For example, a trainee was treating a very bright schizophrenic man in his early 40s. His only mode of transportation to therapy was the city bus. On one particular session day, it was raining relentlessly. The patient was determined, despite the rain, to attend therapy despite the fact that he would have to take the bus, transfer buses twice in the process, and walk four blocks to the psychology office. He arrived at the office, drenched and refused the offer by his therapist to dry off in the bathroom. It was evident that this client had some important work to do in session that day. However, instead of empathizing with the urgency by which the patient needed to see the therapist, the therapist could only focus on his wet state, encouraging him to dry off and assessing, periodically throughout the session, whether he was cold. Finally, after 30 minutes she terminated the session suggesting he go home because she was sure he had to be cold. So after taking three buses and walking several blocks in the pouring rain, which took him approximately 2½ hours, she sent the client home prematurely. Prior to this session, the client had good session attendance; however, after this session he missed the subsequent one.

For almost all beginning practitioners, the acquisition of diagnostic and nosology information is easily attainable. It is somewhat more difficult to learn the nuances of such classification schemes and to attain an understanding of symptoms as they are influenced by individual differences. These unique differences include the person’s ethnic background, primary culture, and subcultures (e.g., drug culture). But through exposure and practice, eventually most clinicians-in-training can demonstrate competency in these areas. However, the educability of clinicians in people skills remains in question. The feasibility of “teaching” empathy has been extensively debated. Some professionals believe that empathy cannot be learned. Others disagree with this premise, professing that empathy skills can be acquired through instruction. Still others offer an alternative axiom between the two preceding premises. These individuals believe that some empathy skills can be taught while others remain partially innate. Irrespective of the theoretical position, if the novice therapist is having difficulty empathizing and conveying care and validation, measures need to determine wherein the problems lie. The burden is on the supervisor or professor to help the novice interviewer elucidate those issues and conflicts that hinder the caring response.

In addition to empathy, validation, and the caring response, there are other therapist “non-specific” variables that may contribute to the success of the interview. These include therapist’s language, use of therapist’s personality and experience, and therapist’s ability to set limits/assertiveness.

Therapist Language

The quality of communication between interviewer and interviewee is an integral part to the success of the interview. In order to obtain a lucid diagnostic picture, it is important for the client to understand what is being asked of him or her. The clarity and comprehensibility of interviewer’s questions will render accurate and pertinent information while facilitating a positive working relationship between interviewer and interviewee. Two linguistic problems of novice interviewers include use of jargon and non-familiar vocabulary. With respect to the former, novice therapists attempt to communicate with vocabulary heavily embedded with psychological mumbo-jumbo. For example, a graduate student asked her new potentially depressed client, “Are you experiencing any vegetative signs of depression?” Now the graduate student risked her client believing that he is either a vegetable or that the therapist is oddly concerned about his vegetarian dietary habits. In two other examples of the use of clinical jargon, novice therapists asked interviewees about a specific behavior, requesting a “functional analysis” of such behavior from one client, and the other therapist asked specifically about the patient’s smoking and overeating habits with respect to Freudian oral stage development. The use of clinical jargon is a method by which the interviewer distances the interviewee from the real issues at hand. The interviewer may or may not do this intentionally. He or she may be uncomfortable with the material being discussed or with the new situation of therapy. Or the use of jargon may be the product of therapist naivete. In any event, most people will not understand the message/request being transmitted, but even if they do, the terms are often abstract rendering many different correct meanings. Finally, the client may become so focused on the sterile clinical term that the psychologically/affectual meaning of the term is lost. At best, the interviewer will spend an inordinate amount of interview time defining jargon for the client.

Similar risks are evident with respect to unfamiliar language. In speaking with clients, the therapist must account for their education level, intelligence, life experiences, and geographic locale. Vocabulary spoken by the therapist should match on these preceding variables. In fact, professionals have found that clients respond favorably to therapists use of clients’ language. Limited swearing would be such an example. There are many terms and phrases specific to various geographic locales and subcultures. For example, in one part of the country the sentence “Momma is going to fix my bottom” means a spanking. But it is always useful to check the meaning of slang or cultural idioms even if the words are germane to the locale. A child from part of the country wherein “fix your bottom” means a spanking, utilized such a phrase in session. Inadvertently (and perhaps a bit serendipitously) in exploring further, the child was actually making reference to an incident of sexual abuse. Another example of geographic or culture-specific language includes the phrase “nervous breakdown.” Most seasoned therapists have heard this term applied to every possible psychological problem (e.g., psychosis, depression, agoraphobia, fatigue). Practitioners not only need to exercise caution in their use of language but need to guide clients in specificity and clarity of their responses to prevent miscommunication.

The sensitivity of language does not suggest the client be “talked down to.” The therapist needs to be respectful of the client. In one glaring example a graduate student said she knew a particular foreign language and could help another student therapist with her case, wherein the client’s mother spoke limited English. The former’s knowledge of the foreign language was actually limited to a few words interspersed with loudly and slowly spoken English. The client, in this case, was not deaf, nor intellectually impaired; she was just not well versed in English. Hence, the therapist needs to monitor the tone, pitch, and volume of voice as well as the speed of delivery and the words chosen so as not to offend clients by “talking down to them.”

Use of Therapist’s Personality and Experience

Our profession has failed to reach a consensus as to the benefits of therapist self-disclosure. For many decades traditional professionals pontificated that therapist self-disclosure should not be used under any circumstances. Others believe there may be a limited use for self-disclosure. But in any situation wherein self-disclosure is advocated by professionals, all believe it should be used sparingly lest the client feel excluded and not understood or, worse yet, the client’s therapy becomes the therapist’s. Although this writer utilizes self-disclosure very sparingly, she has found that once disclosed the communication does not add or elicit new information to the interview nor does it enhance the relationship even when the client presses for disclosure. With respect to the latter, clients will often prod therapists for self-disclosure in an attempt to test the limits of the therapist or therapy (e.g., testing if therapy relationship vs. friendship). Amazingly, often when disclosures are made, the client will continue as if no response were given. There are rare occasions when it appears to add to the process such as therapist credibility (e.g., client is referred for a child problem and they are comforted to know that therapist has own children) or due to very noticeable physical changes in the therapist, such as pregnancy or illness/disability.

Pregnancy can raise a variety of issues for the client including those emanating from their own childhood as well as those that evolve directly from current treatment (i.e., loss of therapist to maternity leave). Personally, this writer is hesitant to suggest the use of self-disclosure to novice therapists as there is a tendency for new therapists to overuse the process. Overuse generally occurs when the therapist is lacking direction (i.e., is lost in session), knowledge, or self-confidence. These three variables are often operative for new clinicians, hence their propensity for self-disclosure when not necessary.

BEYOND THE BASICS

Once the therapist-in-training has attained proficiency in the basics, then the instruction of more advanced skills can be implemented. These include specific techniques focusing on structuring and beginning the interview; building rapport, empathy, and reflection; understanding the presenting complaints; obtaining a social history; extricating a medical history; conducting a mental status exam; writing the intake interview; addressing defensiveness; addressing the over-talkative client; ending the interview; knowing when to refer; and identifying targets for treatment. There are variations in the use of interview components, and this list is not necessarily exhaustive. The way these components are integrated into the interview, and its disposition, will vary by individual client and by interviewer. In the beginning, novice therapists appear disjointed in their attempt to rigidly address all the components. They follow an information gathering formula instead of following the client. Students are so intent on the parts of the interview, that they overlook important information as well as critical aspects of the client-therapist relationship. With practice, many novice therapists are able to integrate the components of the interview without sacrificing the therapeutic relationship. Timing of questions improves such that novice therapists are able to ask questions at the relevant time and to follow-up on a particular of line of questioning in a timely manner.

All of these 12 areas can be covered in an hour to an hour and a half. The progression through the topics will depend on the type of client and his/her responsiveness/resistance to the interview. The amount of structure and type of questions will depend on the client’s style. If the client is not very forthcoming in information, open-ended questions that require patient elaboration are a better choice than closed-ended questions that merely require a yes or no response. However, with individuals who are very talkative and tangential, direct and specific questions including a fair number of closed-ended questions are important in maintaining the structure of the interview. This strategy also enables the interviewer to obtain sufficient information within a reasonable amount of time.

Resistant and defensive patients may perceive frequent use of closed-ended questions as an interrogation, and their defensiveness will increase. Children and adolescents often become more resistant when therapists frequently ask closed-ended questions because it reminds them of their parent or teacher.

CRITICAL ISSUES AND THE INTERVIEW

Referral Source/Referral Questions

The interview is frequently guided by the referral source or referral questions. If a client is referred for treatment or evaluation by a specific person, it is important to determine the role the person has in the client’s life and purpose for referral. The purpose for referral may be very general or the referral source will request specific information of the therapist. For example, the referral may be made by the person’s employer either directly or indirectly by the client. As example, a general referral complaint includes determining problems impacting job performance. A more specific referral question might include determining factors impacting client’s ability to cooperate with coworkers.

Irrespective of referral source, the therapist must clarify as specifically as possible the referral question or problem. In considering our previous example, once the therapist obtains appropriate consent to contact the employer, the therapist gathers as much information about the presenting problem from the employer as possible. It is important for the employer to specifically describe the problematic or concerning behaviors. The interviewer encourages the employer to be concrete and behaviorally descriptive. The interviewer attempts to solicit the frequency, duration, and components of the targeted behavior from the employer. It is helpful if the employer identifies antecedents (e.g., triggers) of the behavior as well as the consequences (others’ reactions). For our example, the therapist has the employer behaviorally define and make operative the terms “problems,” “job performance,” and “cooperation.” In addition, the therapist assesses when and where the behaviors occur, who was present, what did he or she do (consequences for the behavior), and the client’s response to the consequences or responses of coworkers. In addition, the employer is asked to describe previous actions implemented to rectify/remedy the problems, etc.

Although referral sources are limitless, frequently identified sources include ph...

Table of contents

• Cover
• Halftitle
• Title
• Copyright
• Contents
• Preface
• 1 General Issues
• 2 Beginning the Interview and Confidentiality
• 3 Rapport, Empathy, and Reflection
• 4 History of the Presenting Complaint
• 5 Social History
• 6 The Medical History
• 7 The Mental Status Examination
• 8 Writing Up the Intake Interview
• 9 Dealing With Defensiveness
• 10 Dealing With the Overtalkative Client
• 11 Ending the Interview
• 12 Knowing When to Refer
• 13 Identifying Targets for Treatment
• Author Index
• Subject Index
• About the Editors